New Hampshire Advance Directive Page 5
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5I understand the full import of this declaration, and I am emotionally and mentally
competent to make this declaration.
Signed this ______ day of __________________________, 20___.
Principal’s signature: _______________________________________
[If you are physically unable to sign, this directive may be signed by someone else writing
your name, in your presence and at your express direction.]
THIS LIVING WILL DIRECTIVE MUST BE SIGNED BY TWO WITNESSES OR A
NOTARY PUBLIC OR A JUSTICE OF THE PEACE.
We declare that the principal appears to be of sound mind and free from duress at the
time the Living Will is signed and that the principal affirms that he or she is aware of the
nature of the directive and is signing it freely and voluntarily.
Witness _______________________________ Address _____________________________________
Witness _______________________________ Address _____________________________________
If using a Notary Public or Justice of the Peace:
STATE OF NEW HAMPSHIRE
COUNTY OF ________________________
The foregoing Living Will was acknowledged before me
this _____ day of ___________________ , 20___, by _______________________ (“the Principal”).
__________________________________________
Notary Public / Justice of the Peace
My commission expires: _________________________________________
____________________________________________________________, _________________________
(Print Name)
(Date of Birth)
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